Basic Information
| Provider Information | |||||||||
| NPI: | 1912178526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLUMB | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUILDENBECHER | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 827 NE 63RD AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972134337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039275574 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 KATLIAN ST | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077475861 | ||||||||
| FaxNumber: | 9077475415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2008 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6821 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6821 | 01 | AK | STATE LICENSE | OTHER | MD1196 | 05 | AK | MEDICAID |